Perspective

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DNA double-strand break formation and

repair as targets for novel antibiotic
combination chemotherapy
Vincent Amarh1 & Patrick K Arthur*,1
1
Department of Biochemistry, Cell & Molecular Biology, West African Center for Cell Biology of Infectious Pathogens, University of
Ghana, PO Box LG54, Legon, Accra, Ghana
*Author for correspondence: Tel.: +233 20 513 1212; parthur@ug.edu.gh

An unrepaired DNA double-strand break (DSB) is lethal to cells. In bacteria, DSBs are usually repaired
either via an error-prone pathway, which ligates the ends of the break or an accurate recombination
pathway. Due to this lethality, drugs that induce persistent DSBs have been successful in bacterial infection
treatment. However, recurrent usage of these drugs has led to emergence of resistant strains. Several
articles have thoroughly reviewed the causes, mechanisms and effects of bacterial drug resistance while
others have also discussed approaches for facilitating drug discovery and development. Here, we focus on a
hypothetical chemotherapeutic strategy that can be explored for minimizing development of resistance to
novel DSB-inducing compounds. We also highlight the possibility of utilizing bacterial DSB repair pathways
as targets for the discovery and development of novel antibiotics.

Lay abstract: Our health systems face a huge challenge in the form of antimicrobial resistance, which
may result in many common infections becoming untreatable. The same antibiotics that gave modern
medicine its power are fast losing their hold on the germs that cause disease. Many options are being
developed to restore the control that antibiotics have on the microbes that cause many diseases. In this
perspective, we outline a concept that is built around the way and manner in which bacteria mend their
DNA whenever there is a break in the DNA chain. We discuss the merits of finding a new class of drugs
that obstruct bacterial ability to mend their broken DNA. In this scenario, a combination of these new
drugs with existing drugs or other new drugs that cause breaks in bacterial DNA would become a pow-
erful therapeutic regimen. This concept, when fully developed, will offer hope in our effort to combat
antimicrobial-resistant infections.

First draft submitted: 14 March 2019; Accepted for publication: 2 July 2019; Published online:
2 September 2019

Keywords: antibiotic combination chemotherapy • cell-based assays • DNA double-strand break • genome stability
• homologous recombination • nonhomologous end joining • quinolone resistance • ribosome inhibitors • SOS
response • type II topoisomerase

Antibiotic resistance
Antibiotics have been, and still are, instrumental in the global treatment and control of bacterial infections [1–3].
They have also boosted medical interventions, such as surgeries, for which improvement would otherwise have
stagnated due to complications arising from bacterial infections. Thus, antibiotics are indispensable for sustaining
quality global health via eradication of infections caused by bacterial pathogens. It was therefore not surprising for
the WHO to indicate that the increasing prevalence of multidrug-resistant bacterial strains is a primary threat to
global public health [4]. These multidrug-resistant strains have rendered several natural products with antimicrobial
activities obsolete in clinics [5]. However, some of these obsolete antibiotics that had lost their efficacy against
pathogenic bacteria have been resuscitated for use in clinics via chemical synthesis of derivatives of the active
compound [6,7]. Incidentally, these second-, third- and fourth-generation drug derivatives are gradually losing their
usefulness in clinics too due to the development of resistance against their antimicrobial activity.

10.2144/fsoa-2019-0034 
C 2019 Vincent Amarh & Patrick K Arthur Future Sci. OA (2019) 5(8), FSO411 eISSN 2056-5623
Perspective Amarh & Arthur

Collection of extracts and fractions

DSBR-deficient DSB-inducible
cell line cell line

Extracts and fractions with ZOI Extracts and fractions with ZOI
relative to WT (inducers of DSB) relative to WT (inhibitors of DSBR)

Validation and prioritization

Inducer of Inhibitor
DSB of DSBR

Synergy between inducer of DSB and inhibitor of DSBR

Figure 1. Cell-based screening strategy for development of drugs targeting DNA double-strand break formation
and repair in bacteria. A library of extracts (or fractions) are tested simultaneously against a DSBR-deficient cell line
(e.g., a recB mutant of Escherichia coli) and a DSB-inducible cell line (e.g., the E. coli SbcCD/palindrome system [9]). A
WT E. coli cell line, which is unable to generate the inducible DSB, serves as a control for both screening assays.
Extracts (or fractions) that exhibit ZOI against the DSBR-deficient cell line, but not the WT, are designated as inducers
of DSBs. Similarly, extracts (or fractions) that exhibit ZOI against the DSB-inducible cell line, but not the WT, are
designated as inhibitors of DSBR. The synergistic effect of these candidate extracts (or fractions) is validated by testing
in unison against the WT cell line alone. The combination of inducers of DSBs and inhibitors of DSBR that generates
ZOI against the WT cell line is expected to exhibit novel antimicrobial activity against pathogenic strains of E. coli. This
cell-based screening model is also applicable to drug development against other pathogenic bacterial strains.
DSB: Double-strand break; DSBR: DSB repair; WT: Wild-type; ZOI: Zone of inhibition.

The historic antibiotics, such as penicillin, streptomycin, chloramphenicol and tetracycline, were originally
isolated from fungal sources or soil bacteria [8]. Since fungal and soil bacterial species are both diverse in nature,
an enormous amount of research is currently being invested into discovering novel antibiotics from these natural
sources. It is anticipated that these novel compounds might exhibit antimicrobial activity against drug-susceptible
pathogenic bacterial strains and strains that are resistant to antibiotics used for first-line treatments. One underlying
question still remains: is the search for novel broad-spectrum antimicrobial compounds sufficient to helps us with
the menace originating from bacterial resistance to the available antibiotics? A new phenotypic screening approach
that goes beyond the paradigm growth inhibitory assays should be explored for development of novel drugs endowed
with a unique mechanism of action. The rationale would be to systematically develop a set of cell lines that allows
for the detection of new classes of bioactive compounds that target specific and essential cellular processes. The use
of the paradigm cell-based assays is likely to continue to yield the same classes of antibiotics against the same range
of targets for which resistance mechanisms already exist or have evolved. An alternative strategy would be to design
cell-based and target-specific assays that detect new classes of compounds that act synergistically to inhibit the
development of resistance. A pragmatic model of such an assay, which relies on the lethality of an unrepaired DNA
double-strand break (DSB), is shown in Figure 1. The problems associated with screening of natural products are
the high dynamic range of compounds, in terms of chemical diversity and concentration. To address these issues,
the new cell-based and target-specific assay ought to include strategies that improve on selectivity and sensitivity to
many orders of magnitude. An example of a predictive approach for enhancing the sensitivity of cells to inhibitors
of bacterial DNA double-strand break repair (DSBR) is illustrated in Figure 2.

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 Combination chemotherapy targeting bacterial genome stability Perspective

Antibiotic with higher ZOI against DSB- Test for combination of compounds that
inducible cell line relative to WT boost cell sensitivity to DSB

Plate cells on sub-MIC Screen a library of non-

of antibiotic bacteriocidal compounds Media:- compound* and
sub-MIC of antibiotic
Discs:- other compounds
Identify antibiotic-compound*
combination that synergizes ZOI
Establish co-sensitizers of cells to DSBs

Media:- compound*
Discs:- antibiotic Molecular analysis of target gene expression

Validate antibiotic-compound*
combination that synergizes ZOI

Figure 2. A model for enhancing the sensitivity of cells to inhibitors of DNA double-strand break repair. Antibiotics
that exhibit higher zones of inhibition against the DSB-inducible cell line relative to wild-type are predicted to
mediate inhibition of DSBR, thereby sensitizing cells to DSB formation. In order to boost this unique activity of the
antibiotic, a library of nonbactericidal compounds is screened against the two cell lines following exposure to sub-MIC
of the antibiotic. The nonbactericidal compounds that cause a further increase in the zones of inhibition are validated
via a disc diffusion assay in which the agar plate is amalgamated with the compound and the antibiotics are infused
onto discs. The procedure is repeated to demonstrate combinations of nonbactericidal compounds that exacerbate
the sensitivity of cells to DSB formation in the presence of the antibiotic. Analysis of the expression profile of DSBR
genes and associated stress response genes could provide valuable insight on the molecular mechanism underlying
co-sensitization of cells to DSB formation. Importantly, the model could be incorporated into the cell-based screening
assay, described in Figure 1, to identify extracts containing very low concentrations of inhibitors of DSBR.
*Nonbactericidal compound.
DSB: DNA double-strand break; DSBR: DSB repair; MIC: Minimum inhibitory concentration; ZOI: Zone of inhibition.

Bacterial genome stability as a target for antibiotics

Cell wall synthesis, protein synthesis, nucleic acid synthesis and genomic DNA integrity are usually the main
cellular targets of antibiotics in bacterial pathogens [10–14]. Quinolones are examples of antibiotics that compromise
the stability of bacterial genomic DNA.
The lethality of unrepaired DSBs underlies the antimicrobial activity exhibited by the quinolones [10,15–17].
Quinolones bind to the active site of the bacterial type II topoisomerases, following DNA cleavage, to form a
quinolone–enzyme complex, which perturbs re-ligation of the cleaved DNA [18]. This cascade of events leads to
accumulation of DSBs in bacteria that are exposed to quinolones. DNA cleavage by the type II topoisomerases is
a necessity for releasing the torsional stress that accumulates within the chromosome during DNA replication [19].
Consequently, exploiting the function of these bacterial type II topoisomerases to generate lethal DNA damage
made quinolones very effective against a wide variety of bacterial infections [6].

Resistance of pathogenic bacteria to quinolones

Even though quinolones have been used as effective antibiotics, resistant strains have gradually emerged within the
last half century [20]. Resistance to quinolones typically arises via mutations in the genes encoding the DNA gyrase
and DNA topoisomerase IV enzymes [21].
Efflux of quinolones from the bacterial cell and the acquisition of plasmids, which encode quinolone resistance
genes, have also been reported as secondary mechanisms that are utilized by many pathogenic bacteria to confer
resistance against quinolones [20]. Surveillance data have also shown that high prevalence of quinolone resistance oc-
curred during increased usage of ciprofloxacin, which is one of the second generations of the quinolone drugs [20,22].
These observations indicate the need to screen for new molecules with different mechanisms of inducing DSBs.

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Perspective Amarh & Arthur

Quinolones Continuous usage

of quinolones

DSBR-inhibiting compounds/
ribosome-inhibiting drugs

DSB-inducing compounds
Persistent DSB

Cell death Cell survives

(quinolone-resistant cell)
Unrepaired DSB

Figure 3. Cell-based approach for development of combination chemotherapy targeting DNA double-strand break
formation and inhibition of repair. Quinolones generate persistent DSBs in bacteria and eventually cause cell death.
The continuous usage of quinolones for treatment of bacterial infections has resulted in the emergence of strains
which are resistant to the drug. A plausible approach for treatment of infections caused by quinolone-resistant strains
is to administer compounds capable of inhibiting bacterial DSB repair in combination with novel DSB-inducing
compounds. Alternatively, drugs that inhibit the bacterial ribosomes could be used to deplete global protein synthesis,
including DSB repair proteins, thereby leading to accumulation of unrepaired DSBs in the quinolone-resistant strains.
DSB: DNA double-strand break; DSBR: DNA double-strand break repair.

Ideally, the mode of action of these novel antimicrobial molecules should not be dependent on topoisomerase- or
gyrase-mediated DNA cleavage. Strategies that could minimize development of resistance to these new molecules
must also be considered during the initial phase of design of these molecules into drugs.

Novel compounds targeting stability of bacterial genomic DNA

In the quest to identify new drug candidates that compromise the stability of bacterial genome, it is preferable to
screen for novel compounds that generate DSBs and administer in combination with compounds that inhibit the
concomitant repair event (Figure 3). An advantage of this chemotherapeutic approach is the increased sensitivity of
bacterial pathogens to low doses of DSB-inducing drugs due to the effect of the DSBR inhibitors. Consequently,
adverse effects caused by high drug dosage would be circumvented. For example, perturbation of the human gut
microbiome during prolong antibiotic chemotherapy would be minimized by this combination chemotherapeutic
approach [23]. The development of drug resistance due to exposure of bacterial pathogens to high dose of DSB-
inducing drugs might also be minimized by the proposed chemotherapeutic approach.
The DSBR pathway is essential for cell viability because it repairs spontaneous DSBs that are generated during
normal cellular metabolism and growth, as well as DSBs induced by exogenous agents. Compounds that are
capable of inhibiting DSBR are less likely to be efficient drugs when administered alone because the frequency of
spontaneous (uninduced) DSB formation per cell cycle is very low in individual bacterial cells [24]. DSBR-inhibiting
compounds could also boost chemotherapy by increasing the susceptibility of pathogenic bacteria to drugs that
induce DSBs. Incidentally, compounds that inhibit DSBR in bacteria are yet to be discovered and the key strategy
for success will be a cell-based assay using cell lines that have inducible DSB-generating genetic elements.

DNA double-strand break repair pathways in bacteria

In bacteria, DSBs are mostly repaired by either the homologous recombination pathway or the nonhomologous
end joining (NHEJ) pathway. In Escherichia coli, DSBs are repaired by homologous recombination using an
undamaged DNA template [25], which is usually the sister chromosome that is obtained from chromosomal
replication. Even though the key proteins used for NHEJ (Ku and Ligase D) are yet to be discovered in E. coli,
an end-joining activity for repairing DSBs has been reported [26]. The alternative end-joining repair mechanism
was shown to be dependent on the activity of the replicative Ligase A. Other bacteria such as Staphylococcus aureus,
Clostridium perfringens, Neisseria meningitidis and Mycobacterium leprae might rely predominantly on homologous
recombination for repair of DSBs since they also lack the Ku and Ligase D proteins [27]. In contrast, Bacillus
sp., Mycobacterium tuberculosis, Streptomyces coelicolor, Pseudomonas sp. and Xanthomonas sp. encode functional Ku

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 Combination chemotherapy targeting bacterial genome stability Perspective

and Ligase D proteins, which might suggest that these organisms are capable of repairing DSBs via the NHEJ
pathway [27,28]. In fact, previous studies have demonstrated that Bacillus subtilis and Mycobacterium smegmatis use
the NHEJ pathway for repairing DSBs that are generated during the dormant phase of these organisms [29,30].
Besides the homologous recombination and NHEJ pathways, repair of DSBs via the single-strand annealing (SSA)
pathway has been reported for M. smegmatis [31]. SSA was initially shown to be used for repairing a DSB, which
is flanked by homologous DNA repeat sequences in Saccharomyces cerevisiae [32]. It would be critical to determine
which of the two major DSBR pathways is vastly affected during the search for inhibitors (Figure 1). A possible
approach is to use a recA mutant of M. smegmatis which, unlike E. coli, encodes a well-defined Ku and Ligase D
that mediate NHEJ. In-depth analysis of DSB repair in a recA deletion mutant of M. smegmatis can provide insight
on the relevance of NHEJ in development of antibacterial-resistant strains; NHEJ is an error-prone pathway for
repairs of DSBs [33].

Boosting susceptibility of bacteria to DSBs by inhibiting recombinational repair

In bacteria, DSBR by homologous recombination has been studied extensively using E. coli as a model organism.
Recombinational repair of DSBs in E. coli is initiated by binding of the RecBCD enzyme complex to each end of
the DSB. The RecBCD complex processes the ends of the DSB to generate ssDNA, unto which the same enzyme
complex loads monomers of the RecA protein to form a nucleoprotein filament [34,35]. The RecA nucleoprotein
filament catalyses the search for the undamaged homologous DNA and the subsequent strand invasion reaction,
which are fundamental to genetic recombination [36,37]. The strand invasion reaction enables re-synthesis of the
DNA sequences that were lost at the site of the DSB [38]; loss of DNA at the site of the DSB occurs by the action of
RecBCD complex during the initial phase of DSBR [34], and by the activity of the ubiquitous exonucleases in the
cell. The completion of DNA repair synthesis and the resolution of Holliday junctions by the RuvABC enzyme
complex result in the formation of two intact duplex DNA that are separated from each other [39,40]. The key
proteins used for repair of DSBs by homologous recombination are dissimilar in bacteria and humans, hence they
represent potential targets that could be exploited to selectively enhance the sensitivity of pathogenic bacteria to
DSB-inducing drugs.
For organisms that repair DSBs predominantly by homologous recombination, such as E. coli, inhibition of
recombinational repair renders these bacteria to be extremely sensitive to DSBs [9,40–42]. Unlike E. coli, the diverse
pathways for repairing DSBs in organisms such as B. subtilis and M. smegmatis present limitations for exploiting
bacterial DSBR as target for enhancing the susceptibility of these organisms to drugs that generate DSBs. Specifically,
potential drug candidates capable of inhibiting only one of the repair pathways would not render B. subtilis and
M. smegmatis to be very sensitive to DSBs. Nonetheless, if the bacterial NHEJ mechanism is primarily used for
DSBR during the dormant phase of the cell cycle [43], due to absence of a homologous DNA template, inhibition
of recombinational repair could render actively growing cells of B. subtilis to be sensitive to DSB formation. The
existence of a third distinct DSBR mechanism (SSA pathway) in M. smegmatis [31] implies that a combination of
compounds might be required to robustly inhibit repair of DSBs in this organism. Hence, the chemotherapeutic
strategy of inhibiting DSBR in order to increase the susceptibility of bacterial pathogens to DSB-inducing drugs
is intricate for M. smegmatis. This problem can be addressed by using mutant cell lines of M. smegmatis that are
deficient in either the Ku and Ligase D or the SSA pathway to assess the extent to which they contribute to the
repair of DSBs induced by compounds detected in natural product screens. The empirical evidence of this nature
will direct the forward design of DSBR inhibitory targets necessary for improving the efficacy of new DSB-inducing
compounds or the current fluoroquinolones.

Combination of ribosome inhibitors with DSB-inducing drugs to boost chemotherapy

In addition to the fluoroquinolones, ribosome inhibitors are also one of the successful antibiotics that have been
used for the treatment of bacterial infections. Ribosome inhibitors are diverse in chemical structure and they
target components of either the small (30S) or large (50S) subunit of the bacterial ribosome, ultimately inhibiting
protein synthesis [44]. Erythromycin, chloramphenicol, clindamycin and linezolid inhibit the 50S subunit of bacteria
whereas tetracycline, streptomycin, kanamycin and gentamicin are inhibitors of the 30S ribosomal subunit [45].
Chloramphenicol inhibits the bactericidal activity of nalidixic acid, indicating that protein synthesis is a requirement
for the antibacterial activity of the quinolone [46]. Subsequent studies have demonstrated that fluoroquinolones
such as ofloxacin can exhibit bactericidal activity in the absence of protein synthesis [47,48]. These fluoroquinolones

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Perspective Amarh & Arthur

40
E. coli::DSB
E. coli::No DSB

Zone of inhibition (mm)

30

20

10

Amp 10

Amx 20

Van 20

INH 40

Emb 50

PZD 40

Moxi 1

Rif 5

Lin 10

Tet 30

Chlo 30

Ery 20

Strep 15

Cyser 20

Met 30

Gen 10

Para 20

5-fu 1

CyM 0.1
Commercial antibiotics

Control agar plates

15
E. coli::DSB
Zone of inhibition

E. coli::No DSB
10
(mm)

0
1 0.5 0.25 0.125 0.0625 0.03125 0.0156
Amount of streptomycin (μg)

Codeine-containing agar plates

15
E. coli::DSB
Zone of inhibition

E. coli::No DSB
10
(mm)

0
1 0.5 0.25 0.125 0.0625 0.03125 0.0156
Amount of streptomycin (μg)

Figure 4. Interaction of streptomycin with codeine enhances the susceptibility of Escherichia coli to DNA double-strand breaks. (A)
Profile of selected commercial antibiotics against Escherichia coli subjected (or not) to DNA double-strand breaks. Arrows indicate
commercial antibiotics that modestly increased the sensitivity of E. coli to DNA double-strand breaks. These antibiotics are
chloramphenicol (30 μg/μl), erythromycin (20 μg/μl), streptomycin (15 μg/μl) and gentamicin (10 μg/μl). (B) MIC determination for
streptomycin on agar plates containing (or not) codeine. Escherichia coli::double-strand break represents an E. coli strain containing a
system that induces a site-specific DNA double-strand break at the lacZ locus of the chromosome [9]. Escherichia coli::NO double-strand
break represents the control E. coli strain, which is unable to induce the site-specific DNA double-strand break at the lacZ locus.
DSB: DNA double-strand break; MIC: Minimum inhibitory concentration.

require the DNA gyrase subunit A to exhibit bactericidal activity in the absence of protein synthesis; nalA mutants
of E. coli are not sensitive to ciprofloxacin and ofloxacin in the absence of protein synthesis [49].
The Gram-negative E. coli is highly sensitive to very low concentrations of fluoroquinolones in comparison
to the nonfluorinated quinolones, such as nalidixic acid [50]. Below the optimum bactericidal concentration of
fluoroquinolones, the bacteria undergo extensive filamentation due to induction of the DNA stress response
(SOS response) [51]; the SOS response controls expression of several proteins that are essential for repair of DNA
damage [52]. The lethality, which occurs at the optimum bactericidal concentration of fluoroquinolones, was initially
attributed to continuous induction of the SOS response and the concomitant expression of the SfiA protein, which
is an inhibitor of cell division [53]. However, it has been demonstrated that persistent DNA damage generated
by the fluoroquinolones can be repaired by a mutagenic mechanism that is dependent on induction of the SOS
response [54]. Consequently, mutagenic repair of quinolone-induced DNA damage is recognized as a potential
mechanism that can facilitate development of quinolone-resistant strains [55,56].

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 Combination chemotherapy targeting bacterial genome stability Perspective

Since ribosome inhibitors are very efficient in selectively inhibiting global protein synthesis in bacteria, they
could be used in lieu of DSBR-inhibiting compounds, to robustly enhance the susceptibility of M. smegmatis, and
other bacteria with multiple DSBR pathways, to DSB-inducing drugs. Moreover, the use of protein inhibitors in
combination with DSB-inducing compounds could be used for treatment of infections caused by bacteria that
utilizes both homologous recombination and NHEJ for repair of DSBs in actively growing cells. Evidently, the
rationale of this chemotherapeutic strategy is to inhibit the synthesis of DSBR proteins within the bacterial cell
in response to the DSBs in order to enhance their susceptibility to DSB-inducing drugs. The use of ribosome
inhibitors together with DSB-inducing drugs might also be useful for resuscitating some of these individual drugs,
which are currently obsolete in clinic due to development of resistance against their primary cellular target.

Preliminary data from ongoing study

Preliminary data indicate that constitutive induction of a site-specific DSB in a repair-proficient E. coli strain [9]
leads to an increase in sensitivity to ribosome-targeted antibiotics (chloramphenicol, erythromycin, streptomycin
and gentamicin; arrows of Figure 4A). Despite the enhanced sensitivity to this class of antibiotics, the MIC of
streptomycin was unaffected in the presence of DSB induction relative to the E. coli cells that were not subjected
to DSB induction (Figure 4B; control agar plate). This observation implies that inhibition of global protein
synthesis by streptomycin elicits marginal synergy with DSBs against E. coli. However, the synergy is boosted
following addition of a number of well-known compounds (such as codeine), which led to a decrease in the MIC
of streptomycin against E. coli subjected to constitutive induction of DSBs. The modes of action of codeine that
resulted in the lower MIC of streptomycin in the presence of DSB induction are currently unknown and are being
investigated. It is also unknown whether this biological phenomenon is unique to E. coli or can be exhibited by
other pathogenic bacteria. The ongoing work has also identified significant number of fungal extracts falling to the
two groups of compounds that fit the expectations described in Figures 1–4. The important work of isolating the
specific compounds is earnestly underway, the success of which will yield vital new class of antibiotics with new
mechanisms of action to combat drug-resistant infection.

Conclusion & future perspective

DSB formation and inhibition of the concomitant repair event represent distinct molecular mechanisms that
could be targeted for the development of combination chemotherapy against bacterial infections. Homologous
recombination is predominantly used for repairing DSBs in most bacteria, hence it stands out as the preferred
pathway whose inhibition could render these bacteria extremely susceptible to DSB-inducing drugs. For bacteria
that utilize multiple pathways for repairing DSBs, inhibition of global protein synthesis could be targeted to deplete
the DSBR proteins in order to enhance the susceptibility of these bacteria to DSB-inducing drugs.
On the basis of the concepts and approaches discussed in this perspective, it is envisaged that significant advances
will be attained in the discovery and development of novel antimicrobial compounds targeting genome stability. The
use of omics can provide insight on the holistic regulatory landscape for DSB formation and repair. Cellular factors
that modulate the formation and repair of DSBs would be vital novel targets for development of robust antibiotic
chemotherapy. Screening of natural products and libraries of synthetic derivatives would also lead to identification
of novel compounds that exhibit antimicrobial activity via formation of persistent DSBs and inhibition of the
concomitant repair event. Evidence will be reported in literature to explain in great detail the basis for synergy of
specific small molecules that generate DSBs and inhibit the repair in the ESKAPE pathogens (E nterococcus fae-
cium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter
spp.) and fluoroquinolone-resistant bacteria. These achievements would propel preclinical studies to validate drug
candidates that were selected on the basis of compelling evidence from chemical biology. The use of different
animal models for pharmacodynamics would highlight the efficacy of this potential combination chemotherapy
and might possibly reveal pitfalls that were not addressed during the preceding in vitro/in vivo studies. Ultimately,
drug combinations that exhibit synergistic effect against drug-resistant infections are anticipated to be developed
and they should be robust against development of drug resistance.

Acknowledgments
The authors acknowledge J Herrmann of the Helmholtz Institute for Pharmaceutical Research Saarland for critical reading the
manuscript.

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Financial & competing interests disclosure

V Amarh and PK Arthur were supported by funds from a World Bank African Centres of Excellence grant (ACE02-WACCBIP:
Awandare) and a DELTAS Africa grant (DEL-15-007: Awandare). The DELTAS Africa Initiative is an independent funding scheme of
the African Academy of Sciences’s Alliance for Accelerating Excellence in Science in Africa and supported by the New Partnership for
Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (107755/Z/15/Z:
Awandare) and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of
African Academy of Sciences, NEPAD Agency, Wellcome Trust or the UK government. The authors have no other relevant affiliations
or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Open access
This work is licensed under the Creative Commons Attribution 4.0 License. To view a copy of this license, visit http://creativecomm
ons.org/licenses/by/4.0/

Executive summary
This article discusses a strategy for the development of robust chemotherapy against antimicrobial-resistant
infections by:
• Providing insights into the possibility of exploiting the bacterial double-strand break (DSB) repair pathways as
targets.
• Exploring crucial synergistic combinations between DSB-inducing compounds and inhibitors of DSB repair.
• Examining the effectiveness of this new therapeutic regimen in combating antimicrobial-resistant infections.
The proposed chemotherapeutic strategy is discussed as a perspective, highlighting the possibility of utilizing
bacterial DSB repair pathways as targets for the discovery and development of novel antibiotics.

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